Safety and Effectiveness of Insulin Pump Therapy in Children and Adolescents With Type 1 Diabetes

Leslie P. Plotnick, MD, Loretta M. Clark, RN, BSN, CDE, Frederick L. Brancati, MD, MHS, Thomas Erlinger, MD, MPH

Disclosures

Diabetes Care. 2003;26(4) 

In This Article

Conclusions

This study suggests that insulin pump therapy in children and adolescents is safe and effective. There were fewer episodes of severe hypoglycemia and no increase in DKA or ED visits with pump use. There was a small number of easily manageable site infections, none of which required surgical intervention. Although HbA1c increased with time on the pump, this appeared to be attributable to increasing age and duration of diabetes. In other words, regardless of pump status, glycemic control tended to loosen as diabetes duration increased and as children moved into and through adolescence. After adjusting for age and duration of diabetes, HbA1c levels were lower on the pump. We also found that monitoring more than four times per day and greater parental involvement were associated with lower HbA1c levels.

Strengths of this study include data over a wide age range, with children as young as 4 years of age and 29% under 10 years of age at pump start. In addition, we had follow-up data for 3,072 person-months and as long as 6 years after pump start. Also, because of frequent follow-up with the same diabetes team, we had good data capture. Only two patients discontinued pump therapy.

Several limitations of our study deserve consideration. The patients who received the pump were highly selected. The majority of patients were very motivated and demonstrated knowledge of and willingness to do the work of diabetes care. However, our data compare well to other populations of patients using insulin pump therapy.[7,14,15]) It is likely that any patient receiving an insulin pump would undergo similar selection. Thus, although our population may not represent the general pediatric population with diabetes, it is likely similar to other patient populations who are using the insulin pump. Another limitation of this study was that our assessment of parental involvement was subjective. However, parental involvement has been shown to be an important factor in achieving lower HbA1c levels.[16]

Recent comprehensive reviews of insulin pump therapy[17,18] in both pediatric and adult populations show that blood glucose and HbA1c levels are similar or slightly improved when pump therapy is compared with multiple injection regimens. Rates of DKA were similar and hypoglycemia was less frequent with pumps, as seen in our study. Our study adds the dimensions of age and duration as variables affecting HbA1c.

This study has several implications. First, in our population, insulin pump use was safe and effective. The increase in HbA1c with age and duration of diabetes may reflect the progression of diabetes and the reality of daily life with diabetes. After adjusting for these factors, HbA1c was in fact lower after pump placement. Second, our results highlight the importance of modifiable behaviors in achieving optimal glycemic control. Consistent with prior findings, both monitoring frequency and parental involvement were significantly associated with lower HbA1c levels.[16] Thus, personal behaviors, not just the mode of insulin delivery, appear to be important and need to be considered when addressing management issues with families.

In summary, our findings suggest that insulin pump therapy is safe and effective in children and adolescents with type 1 diabetes. Moreover, these data suggest that greater parental involvement may augment the impact of the pump on HbA1c levels. Clinical trials of insulin pump therapy in children with type 1 diabetes could help to clearly define the impact of insulin pump therapy on metabolic control, morbidity, and mortality.

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